Conventionally, when a member of a health insurance plan performs an action that can benefit the member's health, whether a proactive or a condition-specific action or an education program or medical procedure, the member often does not receive incentives unique to that member. Some plans allow for a member's co-pay to decrease. However, this decrease is obtained by manually transferring the member from a first medical pan to a second medical pan in order for the member to obtain this benefit. In that example, the only difference between the first medical plan and the second medical plan is that the co-pay for selected services or procedures as covered by the second medical plan is lower than the co-pay for those services or procedures as covered by the first medical plan. As a result, if an employer desires to offer this option, then the payer must set up and maintain twice as many medical plans. The additional medical plans can become very complicated and very burdensome to manage, especially when the payer or health insurance company wants to report to the employer on the performance of all of the medical plans at the end of the year. It is also difficult to track which members are eligible for which plans and at what point in time. An additional complication falls to providers who are unclear what co-payments to collect from patients at the point of service. If they contact the payer directly to obtain this information, it may be difficult to get a correct response form the payer's customer service representative. Conventional systems are also deficient in effectively communicating to members which programs in which the members are eligible to participate in; displaying the details of those programs; enabling member program enrollment; and tracking member performance. Further, it is difficult to track which employer groups and classes within groups receive certain offerings. Additionally, when presenting an incentive to one member such as a subscriber, it remains questionable whether that incentive should also apply to a subscriber's dependents, such as the subscriber's children.
Conventional claims systems adjudicate claims using the same methodology for all members in a plan and do not have the ability to apply benefits that are unique to a member. Typically, current systems are so inflexible that such a configuration would be extremely difficult to manage and be very difficult to implement on a large scale. Accordingly, it is desirable to have a system that can provide member-specific benefits without any of the above-identified disadvantages.
Participants in a health care system are burdened by the administrative overhead. Different employers have different programs and different vendors. Managing these relationships or even a list of which members are eligible for certain rewards can be very challenging. For example, reward vendors need to be able to verify that the member is really eligible to receive a reward. Additionally, it can be administratively difficult to effectively communicate with health and wellness program vendors in a timely fashion, such as receiving member completion data to trigger reward generation. Accordingly, it is desirable to have a system that provides more administrative efficiency for centralized auditing and tracking.